A member of Minnesota State
Anoka Technical College is an affirmative action, equal opportunity employer and educator and a member of Minnesota State. Accredited by the Higher Learning Commission.
Disclaimer, Non-Discrimination Statement, Student Consumer Information such as graduation rates and median debt, can be found at www.anokatech.edu/AboutATC/Disclosures.aspx.
This document is available in alternative formats to individuals with disabilities by calling the Minnesota Relay Service at 7-1-1 or 1-800-627-3529.
P:\Registration\Forms\Current Forms\Consent for Release of Information 9.19.docx
I, ____________________________, hereby authorize Anoka Technical College (ATC) to release and/or verbally
discuss private education records about me in accordance with the conditions outlined below:
Information may be released to:
__________________________________________; (relationship to student) ___________________________
__________________________________________; (relationship to student) ___________________________
Information to be released includes:
All information.
Information related to admission and demographic information.
Information related to special admission and transfer (PSEO, Concurrent Enrollment, etc.).
Information related to academic performance, class attendance and grades.
Information related to financial obligations and financial aid eligibility.
Information related to appeals, petitions, concerns, and disciplinary action.
Other ______________________________________________________________________________
By signing below, I signify my understanding of each of the following:
I understand that the student information/records listed above includes information that is classified as private
under the Federal Family Education Rights and Privacy Act and the Minnesota Government Data Practices Act.
Without my informed consent, ATC cannot release the information described above because it is classified as
private.
I understand that when my education records are released to the persons named above, ATC has no control over
how the person(s) named above make use of the records that are released.
I understand that, at my request, ATC must provide me with a copy of any educational records it releases to the
persons named above pursuant to this consent.
I understand that I may revoke this consent at any time by giving written notice to the Records Office.
I understand this release expires one year from the date I entered below and that I must submit a new release
form after one year if I wish to provide access to my private educational records.
I understand that I must personally return this form to the Records Office and that staff in that office will verify
my identity by reviewing a photo ID. This is to ensure that I have authorized this release.
Student Signature ___________________________________ Student/StarID _______________________
Date ______________________________
A photo ID is required. Submit completed form in-person to the Records Office, Suite 104.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Office Use Only: Photo ID viewed: Yes or No Viewed By: _______________ Date _____________
Entered into ISRS by Records Office team member: _________________ Date _____________
